Published: 14/07/2005, Volume II5, No. 115 Page 35 36 37

With a scandal-seeking press poised to swoop, the pressure on trusts to tackle healthcare-acquired infections is at an all-time high. Emma Forrest looks at what is being done to beat the bugs

Infection control is in the public eye as never before. Headlines are increasingly dominated by panics, scare stories and tragedies caused or prompted by infection outbreaks.

In the few days before this article was written, Buckinghamshire Hospital trust's Stoke Mandeville Hospital was revealed to be home to a diarrhoea-causing bug that had infected 300 patients and killed 12.

Meanwhile the NHS Logistics Authority was the subject of a tabloid sting operation that swabbed the packaging on medical supplies and found methicillin-resistant Staphylococcus aureus (MRSA) on containers.

And University Hospitals of Leicester trust said it was considering removing bibles from bedside lockers in case they could be carriers of 'superbugs'.

The weeks before had been no different - with the death of a young soldier found to be caused by a new strain of superbug. This came shortly after health secretary Patricia Hewitt outlined plans for a statutory hygiene code for cleaning and environmental standards in hospital.

Proposals include improvement orders and sanctions for trusts and care homes that fail to meet the code. In theory, this could lead to criminal prosecutions.

In short, every facilities manager HSJ spoke to for this article said they were unable to remember a time when infection control has had such a high profile.

'It has always been assumed that it is a high priority but I have never known it to be so in your face, ' says one.

'I do not think facilities managers are under more pressure now than they have been in the past -36 but this is certainly more on the agenda now than ever before. I have been in the service for 27 years and cannot remember the public ever taking such an interest, ' says Andrew Jones, director of allied clinical and facilities services at Chesterfield and North Derbyshire Royal Hospital trust and chair of the Health Facilities Management Association (Hefma).

Mr Jones says the amount of attention the issue is getting has its good and bad points. 'Facilities services are being discussed more now than ever before, which is good.

It is certainly getting discussed more at Hefma than it used to be. Our links with organisations like the Association of Domestic Management are much closer now.

'We are also working to forge links with the National Patient Safety Agency for when they take over the cleaning agenda [the agency formerly responsible, NHS Estates, is being wound down], and with the Healthcare Commission, ' he says. 'Key clinicians are now taking an interest in our services.

'But then you pick up the paper and see another covert operation on an MRSA story. I have colleagues around the country who have had this happen to their trust and it is very damaging and difficult.' With the demise of NHS Estates expected to be complete by September, Mr Jones says some facilities managers have struggled with the new division of central responsibility for cleanliness and the patient environment (some are going to the NPSA and some to the chief nursing officer at the Department of Health).

But the intense scrutiny of work on infection control has aided relationships between clinical and facilities staff.

A number of facilities managers reported that while 10 years ago cleaners were not seen as part of the ward team, that has changed, with cleaners and domestics now reporting to ward sisters and managers. This can happen regardless of whether a clinical manager or domestic services manager is in charge.

'It makes sense for cleaners to be part of a team, otherwise, if you have different cleaners on different days, they cannot get to know the culture of a ward. It does not matter who manages them, ' says Mr Jones. 'There has been much closer working over the past four or five years.'

He believes the Matron's Charter, with its pronouncement that cleaning 'is everybody's responsibility', and the introduction of patient environment action team inspections have contributed to better relationships in work on infection control.

Steve Warren, Hefma vice-chair and director of facilities at Harrogate and District foundation trust, agrees.

'The message is getting through; there is much better co-operation at ward level from porters, domestic staff, doctors and nurses, ' he says.

'We have always taken the view that while domestic staff are part of facilities management, they can be part of the ward team and have been used as a best practice example by NHS Estates on this.' A closer relationship between clinical ward staff and cleaners can aid the cleaning regime on wards.

Clinical staff feel they can negotiate with cleaners about the best times to carry out daily, weekly and deep cleaning and challenge old, ineffective practices.

Recruitment of cleaners can be an issue, however. Swindon and Marlborough trust director of estates and facilities Trevor Payne says, in areas where there is a lot of competition for cleaners such as Oxford and London, it can be difficult to keep staff and therefore difficult to build them into a team.

'You can have the best cleaning regime in the world but that is no good if you cannot keep your cleaners, ' he says.

Mr Payne also expresses a growing concern that scare stories are having too much influence over what the public are led to think about healthcare-acquired infection.

'Some of the issues are getting lost; there has to be a sense check about what we can do and what we can manage. It can be hard to get the public to understand what MRSA is, where it comes from and how it can be stopped.

'It needs to be clarified that a healthcare-acquired infection does not lead to MRSA. There are targets on reducing the rate of infection year-on-year but there is a lack of robust evidence around best practice. We are getting a knee-kerk reaction, ' he says.

'The way that some of the issues and messages are being given to the public on MRSA is unhelpful, ' agrees Mr Warren.

'The public link MRSA to cleaning hospitals and it is not as simple as that. A lot of the stories are very sensationalist.' As Mr Warren's trust has foundation status, a staff governor was involved in its latest patient environment action team inspection, and work involving governors on cleaning strategy will be ongoing. He hopes public governors will be able to educate the public on healthcare-acquired infection issues.

'We only became a foundation trust in January but there are areas where we want to work with the membership and public on education, ' he says.

Although the sense of responsibility surrounding infection control is clearly growing, the prospect of legislative pressure to ensure clean environments is also gaining momentum.

Consultation on the code of practice proposed by health secretary Patricia Hewitt had not been launched by the time this article went to press so details are sketchy. But initial opinion is divided on whether the potential final outcome of such measures, prosecution, will be workable.

'Without the detail we cannot comment in detail but I cannot see how it would work on the ground.

Holding one person accountable is difficult when, as the matron's charter says, we all have to do our own bit, ' says Mr Jones.

However, Mr Warren believes it is reasonable to expect organisations to have someone in place who is ultimately responsible for a hospital being clean.

'It will not be a problem if it is done in a sensible way, even though it is a multidisciplinary process. But in the case of a death, trying to hold an individual responsible can be very difficult unless negligence can be shown. It is also often very unfair.' A health partner at law firm Kennedys, Janet Sayer says such a person would be a board member, most likely the chief executive.

'The trust carries the can, but the difficulty is that an entity cannot be prosecuted; it would have to be an individual. Whether a prosecution could succeed is another issue. The burden of proof - proving beyond reasonable doubt - is much higher in criminal cases.' .



Mental health inpatient facilities have long had a reputation for being, well, a bit grubby.

Campaigners often say that service users have to put up with conditions, that, if they were found on an oncology ward, would make the front page of the Daily Mail.

Mental health has particular problems with keeping its facilities clean. Its patients are usually not bed-ridden and footfall is high. And many mental health providers are struggling to provide care in buildings that are not fit for purpose; they are often ageing facilities that are harder to keep clean and infection-free.

But like the rest of the NHS, mental health trusts are subject to both stringent Healthcare Commission targets on achieving cleanliness, and patient environment action team inspections. Many mental health trusts have now had to up their game.

County Durham and Darlington Priority Services trust decided to go back to basics on its cleaning regime. It created a hotel services manual - a hefty tome described by trust director of facilities Chris Parsons as 'the bible for how we clean everything'. Unusually for a mental health trust, it also recruited an infection control nurse.

Cleaning rotas are adapted to ward need, ensuring cleaning does not clash with meal or medication times.

Crucially, ward housekeepers, who are trained in-house, are part of ward teams and attend meetings.

'It is almost like our patients are spending time in a hotel. They are not bedridden so we want everything to have a domestic, homely feel, ' says Mr Parsons.

The trust's cleaning monitoring officer makes regular checks and provides action plans for improvements. Lessons are communicated around the trust.

At the trust's Auckland Park Hospital, which was highly commended in the clean hospital award at NHS Estates' Building Better Healthcare Awards last year, the hospital provides care for older adults with both functional and organic conditions. It opened in March 2004, and efforts are being made to keep it looking spruce.

'What the judges saw was that this is a team effort, between infection control, facilities and estates. We all have a responsibility, it is not just the job of the housekeeper and hotel services, ' says Mr Parsons.

When an infection such as one that causes vomiting is detected on a ward, the movements of other staff into the area are restricted and families are told they cannot visit. Some patients come into the hospital with MRSA.

'Usually it is living in a wound and the patient is not showing any signs of infection. Having awareness of it in the first place is where infection control comes in, ' says infection control nurse Angela Ridley. 'With something like the Norovirus [the most common cause of infectious gastroenteritis in England and Wales], we treat symptoms like an outbreak until we know otherwise.' It is a big advantage that every patient has a single room, says ward manager Malcolm Allan.

Each room has an ensuite bathroom, which includes a cupboard containing cleaning materials and incontinence pads.

There are also enough cleaning trolleys for them to be taken into a room. 'That way, if we see that a patient has incontinence, it can be sorted out without staff having to leave the room get equipment, ' says Mr Allan.

Senior hotel services supervisor Audrey Parnaby says one way of measuring how clean hospitals are is through patient feedback.

'Patients often feel more comfortable talking to housekeepers than they do staff, ' she says.

Each ward toilet in communal areas features a poster asking patients or visitors to phone hotel services if they are not satisfied with the state of the toilets. 'We have not had one phone call about them, ' says Ms Parnaby.



The liver unit at Leeds Teaching Hospitals trust's St James's University Hospital is acknowledged to be one of the highest-risk areas for infection in the trust.

Ward sister Jackie Hemmings says its patients are particularly prone to infection.

'What gets forgotten is that we now keep people alive when once they would have died.

We have had high levels of infection but we needed to break them down and look at what needed to be addressed.

Our patients are immune suppressed, having often been very sick for a long time and treated with antibiotics over the years, ' explains Ms Hemmings.

She says: 'Small things have made a massive difference. We now have alcohol rubs at the ward entrance and at every bed, and display boards on MRSA and hand-washing. Like every healthcare professional, patients have to be told to wash their hands after going to the toilet.' The ward (in common with other wards at the trust) is closed to visitors once a week, to allow for deep cleaning of the floors and toilets.

Daily and weekly cleaning duties are divided between facilities staff (walls, floors and ceilings, detailed weekly cleans) and nursing staff (nursing stations, monitors, infusion pumps and so on) but Ms Hemmings stresses the importance of making domestic and housekeeping staff part of the ward team.

'If they do not have some sense of ownership for an environment, then you are devaluing them, ' she says.

The trust has invested over£1m in new cleaning equipment:£300,000 on microfibre cleaning cloths, dusters and mops and£750,000 on cleaning machines including 'ride-on scrubber drier' floor cleaners that thoroughly clean floors without leaving wet marks or residue behind (imagine a ride-on lawnmower to get some idea of their size).

The cloths, which contain millions of fibres to take more dirt off surfaces, are colourcoded for different areas, washed after every use and discarded after a certain number of uses.

'The challenges have changed, ' says deputy head of hotel services Craige Richardson. 'The demands are now so high that we have to develop the technology we use.' Director of facilities Keith Lilley says the trust's own 'contract for cleaning' sets out the standards the trust must aspire to.

Software is being developed to design cleaning rotas, so cleaning staff are in the right place at the right time, on a rota that is especially designed for and agreed with each individual ward.

'It is about reassurance. If patients, families and visitors see the standard of cleanliness, then it gives a clear message about our level of service and gives them a level of respect, ' says Mr Lilley.

'We know We are not perfect but We are making progress.' Mr Lilley also stresses the importance of having all cleaning staff buy into the need for a clean working environment.

'They love it when the consultants are going up to them and saying 'I've never seen the place look better', ' he says.

Key points

Infection control is increasingly in the media spotlight.

NHS Estates is closing, causing confusion over cleanliness responsibilities.

The Matron's Charter and the introduction of patient environment inspections will help clarify this.

There are doubts over the assertion that one person could be held responsible for death caused by infection.